* Analgesic Rebound Headache in Children and Adolescents

Analgesic Rebound Headache in Children and Adolescents

John S. Warner, M.D., Director
The Vanderbilt Headache Clinic

In adults the most frequent cause of chronic daily or almost daily headache is analgesic rebound. The pain medication that is taken today only dulls today's headache and causes tomorrow's headache. The exact mechanism for this reaction is unknown. Possibly 1-2% of the population has a likelihood of developing chronic daily headaches if they take some form of analgesic, opiate, or ergotamine on a daily or near daily basis.

At Vanderbilt in recent months we have observed that many of the adolescents and children who present with daily headaches are also experiencing analgesic rebound. Our youngest patient thus far was 5 years of age. The history of these children and adolescents differs somewhat from that noted in adults who have analgesic rebound. The duration of daily headaches is shorter since parents seem to seek an immediate explanation of continuing headache in their children and since pediatricians quickly refer these patients out of fear of a brain tumor or other such condition. Occasionally the parents can recall a specific illness or injury for which the child was given daily analgesics and following which the daily headaches occurred. In contrast to adults, the children are usually receiving over-the-counter analgesics and not receiving sumatriptan and other migraine therapies that are used in adults. In contrast to adults who often try to continue working with these headaches, the children frequently miss school. Children with this condition may be too young to have a history of isolated migraine attacks prior to the onset of daily headaches. After these children experience the onset of daily or near daily dull headaches, they may experience superimposed frequent more intense migraine-like attacks.

There is no laboratory test that detects this disorder. It should be suspected when the patient presents a typical history of daily headaches with daily analgesic usage and the patient's history and examination reveals no other likely cause for these headaches. The diagnosis is established by noting that the daily or near daily headaches cease after the patient stops all analgesic medication.

If the patient with analgesic rebound does not completely discontinue their daily analgesic medications, the daily headaches continue. Our record at Vanderbilt is a 90 year old lady who presented with a history of migraine in her mid 20's followed by 60 years of continuous headache for which she was taking 2 BC Powders (aspirin, salicymide and caffeine) each day. Her headaches ceased after she stopped taking these powders. The time for cessation of headache cannot be accurately predicted in adults. There is no relation to the duration of daily headache, the numbers and types of medications that were used, the presence of a specific illness or injury at the start of daily headache or other factors. Most adult patients will experience termination of the daily headaches within one month of stopping the daily analgesics. Some adults get relief for their daily headaches within one or two weeks. Some adults do not experience relief of the daily headaches until they have omitted all medications for six months. We have the impression that children's daily headaches cease sooner but do not have sufficient experience to state this with certainty. In adults we note that if the patient stops daily medicine but continues taking an over-the-counter analgesic once or twice each week, the daily headaches continue. Therefore we recommend that adults, children and adolescents omit all analgesics until they experience one or two weeks of complete freedom from all headaches. Many adults with this condition who obtain relief from their headaches after ceasing the offending medications will note reoccurrence of their daily headaches if they resume taking daily medications at some time in the future. This appears to be a life long problem.

While experiencing the daily headache of analgesic rebound, all medications that are given to prevent migraine from occurring (amitriptyline, popranolol, Depakote) are ineffective. We therefore stop these medications when we instruct the patient to stop the daily analgesics.

We seldom obtain laboratory studies on these patients and treat them effectively as outpatients. We can prescribe simple agents for nausea and sedation that can be used as necessary while the daily headaches continue.

If there are further questions regarding analgesic rebound headache, you may call this office (615-936-0216) or the clinic nurses (615-343-9512).